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any simple sense. They necessarily model it. This modeling within classification systems of all sorts is where the rubber hits the road in terms of the enfolding of social, political, and organizational agendas into the scientific work of describing naturein this case in the form of disease entities. |
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Interpretation Is Also Enfolded into the ICD |
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We saw in the last section how the ICD cuts the world up into standard Aristotelian unities of time and place and in so doing how it produces favored readings of the body and of the world at large. The WHO goes one step further. It not only provides, through the ICD, a set of possible stories it also provides, bundled up in the classification system, explicit rules for the interpretation of those stories. |
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To follow this through, we need to look at the form of the standard international death certificate (see figure 2.3 above). Anne Fagot-Largeault (1989) and Lennart Nordenfelt (1983) have produced wonderful philosophical analyses of this document; our own description will not attempt to be as complete. It is the death certificate that constitutes the archetypal use of the ICD; indeed, until ICD-5, the classification only covered causes of mortality and did not seek to represent morbidity. The death certificate itself has as a major heading, "cause of death." It is split into sections, "cause of death," "approximate interval between onset and death," and other contributing factors or significant conditions. |
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It is a hard job to boil down a complex series of conditions to a single cause of death; and the work of interpretation begins on the form itself. A single cause is favored for very practical reasons. In the first place it is hard enough to compile statistics at all; the task could get overwhelming if multiple causes were allowed. Further, a single cause of death provides the lowest common denominator over multiple collection systems, from medical examiners in a large hospital to medical paraprofessionals in underdeveloped rural areas. Finally, as the ICD's developers point out, the goal of the classification system is not to describe complex phenomenologies, but to prevent death: |
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From the standpoint of prevention of death, it is necessary to break the chain of events or to effect a cure at some point. The most effective public health objective is to prevent the precipitating cause from operating. For the purpose, the underlying cause has been defined as "(a) the disease or injury that initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence which produced the fatal injury." (ICD-10, 2: 31) |
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